TRENTON, N.J. – Drugmaker Merck & Co. has granted a free license allowing one of its HIV medicines to be made and sold inexpensively for use in young children in poor countries hard hit by the AIDS virus.
The deal, announced Tuesday, lets any generic or brand name drug manufacturer make low-cost pediatric versions of Merck’s raltegravir for sale in 92 low- and middle-income countries, according to the Medicines Patent Pool. The group, backed by the United Nations, works with brand-name drugmakers to find ways to make their HIV medicines still covered by patents available in developing countries for a fraction of the price charged in Europe or the United States.
Merck, based in Kenilworth, New Jersey, sells raltegravir under the brand name Isentress. In the U.S., it costs about $1,350 a month without insurance.
The patent pool is now starting to line up manufacturers to produce raltegravir for poor countries, where the patent runs until about 2022. Based on prior licensing deals made by the group, the pills could be priced between 47 per cent and 87 per cent less than Isentress now costs.
According to the Geneva-based organization, about 98 per cent of children with HIV live in India, South Africa and other developing countries. That’s because unlike in wealthier countries, their mothers aren’t likely during their pregnancy to be tested for HIV and given medicines to prevent transmitting the virus during childbirth.
“Without antiretroviral therapy, 50 per cent of infants living with HIV/AIDS will die by the age of 2, and 80 per cent by the age of 5,” Dr. Deborah Birx, U.S. global AIDS co-ordinator, said in a statement.
Few medicines are approved for children with HIV under age 3, but raltegravir is — for those as young as 4 weeks old.
The deal supports efforts by the Pediatric HIV Treatment Initiative, a collaboration including the patent pool and other health charities, to develop better medicines for HIV-infected children, including liquid and chewable forms easier to take than pills. Raltegravir already is available as chewable tablets and in a dissolvable powder.
Two months ago, the patent pool signed a similar license with AbbVie Inc. allowing use of inexpensive versions of its HIV medicines, lopinavir and ritonavir, for children. Those drugs are sold in combination pills under the brand names Aluvia and Kaletra.
The patent pool says Merck’s medicine could become an alternative to the current initial HIV treatment for children and become part of future combination therapies for them. Meanwhile, raltegravir is now being tested for possible use in newborns.
Thanks to the widespread availability of antiretroviral therapy (commonly referred to as ART or HAART) in Canada and other high-income countries, researchers increasingly expect that some young adults who are infected with HIV today and who are diagnosed and begin treatment shortly thereafter will likely live into their eighties.
Some people with HIV infection may experience liver injury because of co-infection with hepatitis B and/or C viruses. In some cases of severe liver injury, a liver transplant may become necessary.
Doctors in Vancouver, British Columbia, have had experience performing a limited series of liver transplants in HIV-positive people. So far, all four patients who received liver transplants have recovered from surgery and are doing well.
Organ transplantation involves complex processes and procedures, ranging from screening and interaction with a multidisciplinary team (including a psychologist and social worker to assess a patient’s suitability for transplantation) to monitoring and counselling through surgery and care. There are infections after surgery that need treatment and also the long-term use of transplant medicines that require complex monitoring and dose adjustment. All of these many steps require frequent medical care.
A change in transplantation assessment
Until relatively recently, despite a clear medical need for organ transplantation, such procedures were rarely carried out for HIV-positive people because of a number of concerns, including the short life span of patients and fear of the transplant team becoming infected with HIV either during surgery or via needle-stick injury. However, thanks to the educational and advocacy efforts of patients, infectious disease specialists and policy planners, HIV-positive people can now be considered for organ transplantation in B.C., Ontario and elsewhere. Furthermore, concerns about the safety of the transplant team in B.C. were resolved after the first surgery for a co-infected person when the transplantation team deployed universal precautions against HIV infection and no one became inadvertently infected.
The experience in Vancouver
Doctors in Vancouver—including infectious disease specialists and transplant surgeons—reviewed the medical charts of 28 HIV-positive people whose doctors referred them to the B.C. transplant program for evaluation for a possible liver transplant.
After referral by their doctor for screening for an organ transplant, the transplant team’s social worker and psychologist interview and counsel candidate patients. Additional staff from the transplant team, including nurses and surgeons, also meet and get to know the patient.
After a candidate patient has been favourably assessed for a transplant, he or she is placed on the waiting list. HIV-positive people (like HIV-negative people) have to be successfully assessed and meet the following general criteria for transplantation:
no active infections (such as those that can cause life-threatening infections)
no active substance use
HIV-positive people should be on ART and under the care of an HIV specialist
HIV viral load should be under the level of detection (commonly called “undetectable”)
HIV-positive people should have at least 150 CD4+ cells/mm3
Overall, the transplant program received referrals for 28 HIV-positive patients. Their average age was 47 years; 74% percent were male and 25% were women.
Most patients referred to this program were from B.C., although doctors stated that “some were from other Canadian provinces and one was from the U.S.” All patients had chronic liver disease.
Common co-existing health conditions among referred patients included the following:
anxiety and/or depression
inherited bleeding disorders
Common causes of liver disease included infection with hepatitis-causing viruses.
Of the 28 referrals, 23 returned for assessments at the Transplant Program. Of these, five were considered suitable for transplantation. These five patients had the following pre-transplantation complications and/or co-infections:
severe liver injury caused by the immune system attacking the liver (autoimmune hepatitis)
a liver that had become very fatty and injured from excess deposits of fat
hepatitis B virus and delta infections
hepatitis C virus
One patient died while on the transplant waiting list (this patient was from another province).
The vast majority of the 23 assessed patients were not placed on the waiting list because the transplant team deemed their liver disease as “stable.”
Focus on the four patients
Patient 1 received a liver transplant at 59 years old because of autoimmune hepatitis. According to the doctors, he has been medically stable for more than six years after his transplant. His HIV is well controlled. His initial immunosuppression (affected by transplantation drugs) consisted of the following medicines:
mycophenolate mofetil (CellCept)
gradually increased doses of corticosteroids
He developed kidney injury while taking tacrolimus but has since recovered and now uses CellCept. His transplanted liver is healthy.
Patient 2 received a liver transplant at age 55 because of a fatty liver. Three years after transplantation, his HIV is well controlled with the following three drugs:
a fixed-dose formulation of abacavir + 3TC (Kivexa)
He was given the same three transplant drugs as Patient 1. There have been no interactions between his transplant medicines and HIV treatment. His new liver is healthy.
Patient 3 received a liver transplant at age 49 because of HCV co-infection. He also received the same trio of transplant medicines as the other patients. However, three months after transplantation, HCV infection recurred. As a result, doctors performed additional blood tests and he underwent a liver biopsy.
Two years after transplantation, the levels of the waste product bilirubin in his blood were elevated but his levels of liver enzymes in the blood (suggestive of liver inflammation) had decreased.
Two years and three months after his liver transplant, the patient suddenly developed fluid build-up in his abdomen, suggestive of ongoing liver injury and inflammation. Doctors are planning to treat him with an interferon-free regimen of HCV drugs in the future.
Patient 4 was co-infected with hepatitis B and hepatitis delta viruses. In addition, he developed liver cancer. Immediately after transplantation he developed several complications, including bleeding and kidney injury. As a result he required prolonged hospitalization and rehabilitation. However, his overall health is now stable and tests have not detected hepatitis viruses in his blood samples.
Factors for success
The B.C. doctors said that the main reasons for their patients’ generally successful course and survival after transplant were the presence of the following members on the transplant team:
specialists in transplant medicine
specialists in HIV medicine
The study authors made the following statement:
“Patients were selected for transplantation based on [the presence of severely worsening liver disease]. There is absolutely no bias against the HIV-infected individual; in fact, we have been their advocates.”
The B.C. doctors added that “…our three long-term transplant patients are the longest surviving HIV-positive transplant recipients in Canada and were the second, third and fourth HIV-infected patients to receive liver transplants in this country.”
The doctors found that the care and treatment of co-infected patients was challenging. However, they note that there are clearly some patients who experience good long-term health after transplantation.
Building on success
The B.C. doctors are hopeful that their positive and successful experience will encourage doctors in other parts of Canada so that organ transplantation for HIV-positive people will become more common.
—Sean R. Hosein
Tan-Tam C, Liao P, Montaner JS, et al. HIV and liver transplantation: The British Columbia experience, 2004 to 2013. The Canadian Journal of Infectious Diseases & Medical Microbiology. 2014 May;25(3):159-62.
For much of the past decade in Canada and other high-income countries, the mainstay of hepatitis C treatment has been a combination of the following two drugs:
a long-acting form of interferon-alpha called peginterferon
Peginterferon works by activating genes in a cell that then produce many antiviral substances. In general, it is difficult for hepatitis C virus (HCV) to counteract the action of these genes. This is why peginterferon has, until very recently, been the backbone of HCV treatment.
Ribavirin is a nucleoside analogue and has activity against a broad range of viruses, at least in laboratory experiments with cells. Exactly how ribavirin works against HCV-infected cells is not clear.
The debut of DAAs
As mentioned earlier, the historical mainstays of HCV treatment were drugs that affected HCV indirectly. However, in 2011 the first licensed direct-acting antivirals (DAAs) for HCV became available:
These two drugs belong to a class called protease inhibitors. Boceprevir and telaprevir were taken orally but needed to be used with interferon and ribavirin. Furthermore, regimens containing either of these DAAs were largely only effective against one strain of HCV—genotype 1. Both regimens were associated with side effects, had to be taken for prolonged periods and their effectiveness was not very high—if patients completed their course of therapy, recovery rates ranged from 60% to 75%.
Fortunately, today more DAAs are being approved and can be used without interferon. What’s more, therapy with newer DAAs is generally shorter (12 to 24 weeks) compared to regimens several years ago.
In this issue of TreatmentUpdate, we largely focus on several combinations of agents including these:
sofosbuvir (Sovaldi) with ribavirin and/or peginterferon
simeprevir (Galexos, Olysio) with sofosbuvir
Holkira Pak (nick-named the “3D” regimen) made by AbbVie.
In the next issue of TreatmentUpdate (issue 208) we will have detailed information about another exciting HCV therapy called Harvoni (sofosbuvir + ledipasvir) that is made by Gilead Sciences.
In Canada and other high-income countries, most people cannot afford to pay for the high cost of treating and managing catastrophic illnesses such as HIV, HCV and cancer. In response to this situation, regional health authorities have established formularies—lists of drugs that are subsidized by the state.
Until a drug is listed on the formulary, most patients cannot get access to it, though some companies may have very limited compassionate access programs for people with HCV. Some patients may also be able to access these drugs because they have private health insurance.
The formularies negotiate with pharmaceutical companies about the cost of their drugs. This back and forth between the formularies and companies takes time. The cost of the new DAAs will be high and it is not clear when they will be on every formulary.
The high cost of the new regimens may mean that access to the new DAAs will be delayed and rationed. Formularies can put restrictions on who can get their listed medicines. For instance, it is possible that some formularies may insist that there be conditions on access—this may include issues such as the stage of liver injury, such that only the healthiest patients (who generally have the highest rates of recovery) or the sickest (whose need for medicines is greatest) get treatment. Alternatively, if a good bargain is struck by formularies, there may be few or no restrictions on the use of new HCV therapies.
Clinical trials and reality
The new all-oral DAA regimens being developed by AbbVie and Gilead generally have very high success rates—ranging from 95% to 100%—depending on the sub-populations being tested, at least in clinical trials. However, in the real world outside of a clinical trial, doctors have come to expect that medicines may not perform as well for many conditions. Perhaps this happens because patient populations in clinical trials are usually highly selected and do not always reflect the diversity of illness that occurs in the real world. In general, clinical trials usually do not enroll the sickest and hardest-to-treat patients.
The cost of initial treatment with DAAs is relatively expensive. What happens if a new regimen fails to cure the patient? Arguably, given the potency of the new DAAs such cases should not be common, particularly among patients who have never been previously treated. However, in cases of treatment failure will the state agree to pay for another course of a different but equally expensive DAA-based therapy? Will insurance companies also agree to pay for retreatment if an initial regimen of DAAs fails? Cases of reinfection may occur if successfully treated people are again exposed to HCV—how will the state deal with this issue given the high cost of therapy? These are just some of the issues that could become controversial in an era of enforced austerity.
Cost and access
These issues of rationing are sufficient reason why people with HCV and organizations that serve them need to monitor what formularies are doing in order to understand how these organizations arrive at decisions that can impact the health and survival of the population.
For the future
Although new, powerful regimens are being licensed by regulatory authorities, it is not clear which medicines will become available on formularies early in 2015 and much work remains to be done.
—Sean R. Hosein
Pollack A. AbbVie deal heralds changed landscape for hepatitis drugs. 22 December 2014. New York Times. Available at: http://tinyurl.com/ppesz7h[registration or subscription may be required].
Jerzyk E. Rhode Island Medicaid limits supply of hepatitis C drug due to cost. The Brown Daily Herald. 4 December 2014. Available at:http://tinyurl.com/o7xxtse
The once-futuristic notion of robots helping patients is now a reality in several hospitals and clinics in Saskatchewan.
There are 11 medical robots and portable devices in clinical practice in the province, more than anywhere else in Canada.
Dr. Ivar Mendez, a Saskatoon neurosurgeon, is pioneering the clinical use of remote presence technology. This innovation uses an ordinary cell phone connection to video-link specialists with patients so they can perform real-time diagnosis and monitoring.
Mendez started testing robotic medicine in Nova Scotia as well as Newfoundland and Labrador, prior to expanding the technology’s use in Saskatchewan after arriving at the University of Saskatchewan in 2013.
There are currently five robots, roughly 1.5 metres tall, and six portable devices about the size of a briefcase called “doctor in a box.”
The implications of this go far beyond traditional telehealth.
Physicians can use smartphones to remotely control a robot and interact via video-link with a patient. But, more importantly, the doctor — with assistance — can connect diagnostic equipment such as stethoscopes, ultrasounds, and electocardiagrams to see, touch and hear the patient.
“This is going to revolutionize the way we deliver health care, not only in Canada but in the rest of the world,” Dr. Ivar Mendez told CBC News.
Here are 5 ways it’s already happening:
1. Robot on reserve
A robot named Rosie is stationed in the First Nations community of Pelican Narrows, Sask., a six-hour drive northeast of Saskatoon.
CBC News visited the remote medical clinic to capture a virtual appointment on camera. In the above video, watch Saskatoon physician Dr. Tanya Holt take control of Rosie to examine a critically ill toddler on the remote reserve.
If it weren’t for this technology, an ambulance or airlift would have taken the 11-month-old boy to a larger centre.
Sick or injured people in Pelican Narrows are forced to make thousands of exhausting and expensive publicly-funded trips out of the community. Last year, there were 750 emergency medical evacuations and another 5,000 patient transfers to cities such as Prince Albert, Sask. or Saskatoon to see specialists, get tests or receive dialysis.
The provincial government is paying for this $250,000 pilot project in partnership with Peter Ballantyne Cree Nation.
In 2010, Dr. Mendez ran a similar pilot project in an Inuit village in Labrador that showed the technology led to a 60-per-cent reduction in medical evacuations.
2. Ambulances using ‘doctor in a box’
When a person is seriously injured in a car crash on the highway, emergency room physicians must wait for that patient to arrive at the hospital to perform scans and determine treatment.
Dr. Ivar Mendez telestreams in “doctor in a box,” manufactured by California company InTouch Health. (Submitted: Dr. Ivar Mendez)
Now, a pilot project has trained 12 paramedics and eight emergency room physicians at the Royal University Hospital in Saskatoon how to use the “doctor in a box” while in transport.
The doctor can tele-stream into the ambulance, see the patient, advise the paramedic and conduct an ultrasound before the ambulance arrives at the hospital.
3. Robotic house calls for HIV patients
This is a high-tech version of the traditional country doctor house call.
A nurse in the North Battleford, Sask. area can visit HIV patients at home or set up a mobile clinic that features the portable doctor-in-a-box. This connects those patients with an infectious disease specialist in Regina, Dr. Stuart Skinner, who can speak to the patients and perform diagnostic tests.
“If all is needed is a medication review or check, we can do that remotely rather than have the patient travel three hours each way for what amounts to a 10 to 15-minute visit,” Skinner said.
4. Surgical rounds
When Dr. Mendez, the neurosurgeon, goes to a conference in Regina or Toronto, he can still perform his morning rounds or supervise a surgery using a robot stationed at the Royal University Hospital.
Mendez can activate the robot from his smart phone and, with assistance from hospital staff, perform diagnostic tests on patients.
There are two robots in Royal University Hospital and one in Regina General Hospital.
5. Humanitarian work around the world
This boy in the Bolivian Andes was ostracized in his remote village because his skin looked like dry fish scales. (Submitted: Dr. Ivar Mendez)
Dr. Mendez practises humanitarian medical care with a “doctor in a box” in his birth country of Bolivia.
A trained worker in Bolivia carried the portable device to a remote village in the Andes to connect a young boy with pediatric specialists in Canada.
According to Mendez, the boy, Johnny Quispe, was ostracized in his community and unable to attend school because of a rare skin condition that looks similar fish scales.
Before and After pictures of boy with rare skin condition in the Bolivian Andes. (Submitted: Dr. Ivar Mendez)
Using remote presence technology, specialists used microscopes and diagnosed the boy with a condition known as hereditary ichthyosis. The specialists sent a medical skin cream to the remote village and the Quispe’s condition has improved.
Mendez also runs a program that gives prenatal exams and ultrasounds on pregnant women in that region.
Barriers in current health care system
These pilot projects are testing everything from cost savings to patient satisfaction.
However, Mendez said expanding the use of remote presence technology will challenge policy-makers to redesign the system. The ability to connect doctors and patients in different regions, and across borders, will require a new system of oversight and physician billing.
As the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) got underway in Seattle yesterday, February 23, we spoke with Dr. Carl Dieffenbach, Director of the Division of AIDS at NIH’s National Institute of Allergy and Infectious Diseases (NIAID). He discussed what we can anticipate hearing more about during this annual scientific meeting that brings together nearly 4,000 researchers from around the world to discuss their work to understand, prevent, and treat HIV/AIDS and related infectious diseases, including hepatitis C virus (HCV) infection and Ebola.
Dr. Dieffenbach pointed specifically to HIV prevention study findings that will be presented throughout the four-day conference. These include findings from a number of NIAID-supported studies such as the PROMISE study on the prevention of mother-to-child HIV transmission and the HIV Prevention Trials Network (HPTN) 065 study on the feasibility of an enhanced test, link to care, plus treat (TLC-plus) approach for HIV prevention. He also acknowledged findings from the FACTS study of a vaginal microbicide gel to protect women against HIV infection.
Noting that a number of studies on HCV will also be presented at the meeting, Dr. Dieffenbach observes that the advent of new curative treatments for HCV present an important opportunity not only to cure a common HIV co-infection but also to draw co-infected individuals into – or back into – care for their HCV infection and use that as a stepping stone for engaging them in HIV care and treatment.
With more than 1,000 study abstracts to be shared for the first time at this conference, Dr. Dieffenbach also looks forward to study findings on efforts to improve outcomes along the HIV care continuum for various populations and studies that will inform the continuing search for an HIV cure.
Tomorrow Dr. Dieffenbach will return to share brief highlights of the science presented on Tuesday, February 24. We will also begin sharing some interviews by Dr. Ronald Valdiserri, Deputy Assistant Secretary for Health, Infectious Diseases, with federal colleagues who are attending CROI 2015.
For Matthew Cutler, director of development and community engagement at the 519 Church Street Community Centre, the end of Xtra marks a turning point for queer visibility.
“I used to travel out to Mississauga through Kipling Station and was always amazed to see the Xtra box there,” he says. “I think that sometimes folks in the neighbourhood take it for granted, [but] the presence of Xtra in physical form played a large part in telling that story to a community that otherwise wouldn’t have heard about it.”
Since Pink Triangle Press (PTP) announced that it would be shuttering its print division, not-for-profit organizations like The 519 have had to assess how the move will affect their ability to reach Toronto’s LGBT communities — especially people who live in outlying areas of the city.
“Although we have a geographic catchment that calls us to serve the Village and the broader lesbian, gay, bi and trans community in the city, the vast majority of our members don’t live here,” Cutler says. “[And] for many in poor and marginalized communities, they simply can’t afford to live in this neighbourhood. So Xtra being out in the space helped us to draw those people in and keep them up to date.”
Arti Mehta, LGBTQ coordinator at the Canadian Cancer Society, agrees. The biggest drawback of the paper’s demise is losing “the visibility of LGBTQ community issues in everyday environments,” she says. “It has been great to work with a publication that focuses on LGBTQ communities, as we know we are reaching the right target market.”
When PTP launched the paper in 1984, Xtra’s mandate offered many organizations a platform to discuss issues pertaining to LGBT people that were often ignored by mainstream media outlets. And at a time when the community was disproportionately affected by the HIV epidemic, the paper acted as a valuable resource for those looking for programs and services that could improve their quality of life.
“One of the challenges throughout the HIV epidemic has been the under-representation of LGBTQ issues, and specifically health issues, in the mainstream media,” says Chris Thomas, communications coordinator at the AIDS Committee of Toronto. “Xtra’s audience is largely made up of folks from the LGBTQ community, so for us it has been a no-brainer” to use the paper for outreach.
Cutler agrees. The 519 “would often struggle to get mainstream media to cover us because we were often marginalized as an LGBT agency. Even as recently as five or six years ago, we would have to fight or really work hard to get coverage in other outlets, while we could reliably turn to Xtra to tell our story.”
And while the paper was helpful in supporting organizations and advancing their issues, it also played a key role in holding them accountable to the community at large.
“I often think about decisions we make or work we do in terms of how Xtra would cover it,” Cutler says. “And that, sometimes, is a measure for me of where we might need to do more work or something we’re doing needs a little bit more attention. Xtra helped to keep us honest and keep us thinking about how we’re intersecting with the broader community in the work that we do.”
According to the most recent study by research agency NADbank, newspaper readership remains strong across the country, with 15.8 million Canadians reading some form of newspaper content each week and six in 10 preferring to read their news in printed versus online editions. Still, NADbank notes that online readership is steadily gaining on print, with one in three Canadians reading at least a portion of their news content online from established publications.
“As much as I think we will all miss the print edition of Xtra, it is not a surprise that a shift to digital is in order,” Cutler says. “The web began to be more of a traffic point for us than print, and it gives us an even broader audience.”
He argues that while the physical paper extended the organization’s reach into the suburbs, the online version can get the word even further. “We know that even on our own website, we see a large number — not a majority, but certainly in the 30- to 40-percent range — of visitors from outside the GTA and outside Canada in some cases.”
Thomas sees similar trends at his agency. “A lot of people looking to have sex in the LGBTQ community are using online apps and other types of digital platforms to meet each other. Accordingly, [ACT has] been increasing our presence on many of these sites to promote safer-sex practices and strategies for reducing the risk of getting HIV and other STIs when having sex. Moving forward, we will continue to partner with Xtra digitally, should the opportunity present itself and the circumstances be mutually beneficial.”
Cutler is optimistic about the shift online and views it as an opportunity to increase the breadth of representation and to be more precise in targeting specific demographics. He hopes that it will allow people to find information that is specifically relevant to them.
“When you have a limited number of pages, you have to be selective about what ends up in a paper. And that’s not to say that you don’t curate an online environment, but that you can be broader because you’re not as limited in what you do. My hope is that as these conversations move more online, it will allow us to represent a greater diversity of our community and the people who are in it — because we have more bandwidth and space to play with.”
Fresh from a nap, little Isaiah is hungry. As his mom cradles him in her arm and sinks into a padded sofa, his cries for lunch are reduced to the satisfied whimpers of a baby who knows he’s about to be fed.
She curls up, bottle in hand, and tucks in her bare feet, cross legged. On top of her left foot, are the tattooed footprints of each of her two boys. The left foot of baby Isaiah and the right foot, shrunk to baby size, of 2 1/2-year-old Noah. She had them permanently marked into her skin shortly after Isaiah was born, a silent testimony of her love for her sons.
“There’s a little piece of them on me forever,” she says.
As Isaiah suckles from a bottle of formula, and Noah busies himself making pretend food in their St. Catharines apartment, 29-year-old Janelle Hellewell talks about her children.
When they are old enough, she will probably cuddle them on this very sofa and tell them the story of her life and their birth.
She might tell them how 20 years of medical advancements intersected with her longing to be a mother. And how, in a country like Canada, an HIV-positive mom can give birth to healthy babies and live a long, healthy life herself.
In the time before effective treatment, it used to be that one in every four babies born to an HIV-positive mom, would be infected, says Sean Hosein, Science and Medicine Editor at CATIE, the Canadian AIDS Treatment Information Exchange.
In fact, before 1997 when powerful anti-HIV drug therapies began saving lives, HIV-positive women were advised not to get pregnant or to have an abortion if they did, he says.
But in the last two decades, those so-called “drug cocktails” – called ART for anti-retro viral therapy– have become so effective that people who otherwise died of AIDS in the epidemic of the mid-1980s, are living. They have a future. A near-normal lifespan.
In fact, researchers have found that over the last decade, the life expectancy of people who are HIV-positive is almost equal to the expected life of someone who is negative, he says.
For example, they predict a 20-year-old person in Canada who begins ART soon after becoming HIV positive, should live to about 70 years. That’s assuming they have no other health issues such as addictions or mental illness.
“This is a tremendous change in HIV treatment and survival,” he says.
“And given such a promising forecast, some people are thinking of having families.”
Indeed, it’s those very drugs that have nearly eliminated the risk to babies.
In Canada, the rate of mother-to-infant transmission is about 0.4% for woman who follow specific guidelines and start anti-HIV drugs well before the last four weeks of pregnancy, says Hosein.
“It’s very exciting,” he says.” You can have a safe pregnancy and a healthy baby.”
One of the most important ways to reduce the risk of transmission, is by mom taking anti-HIV drugs while she’s pregnant, he says. The idea is to keep a woman’s viral load – the amount of HIV in her body – to “undetectable” levels, he says.
A word of caution though – some drugs can harm the fetus and cause birth defects, especially if taken during the first trimester, so it’s important to get medical advice.
In addition to ART, the mother must also receive intravenous AZT – an anti-HIV drug – during birth and when warranted, deliver by C-section, not vaginally. The baby also must receive anti-HIV drugs for a few weeks after its born. And mom cannot breastfeed.
In 2011, the most current year for statistics, there were 203 babies born in Canada to HIV-positive moms. Three infants were positive, says Hosein.
Needless-to-say, all this has made a world of difference to Janelle.
Her life is about being a student and working on her high school diploma. It’s about her faith, and trust in her God. It’s about staying true to herself. It’s about being a mother. And it’s about having a future.
She is reminded of HIV once a day when she takes a pill, and every three months when she has blood work.
“HIV is just a disease I have. It doesn’t define me,” she says.
“I know people might say, you’re a write-off, you’re dirty, you deserve it. That’s not true. I’m a mother. I’m a student. I’m a daughter and I’m a Christian woman.
“And I have a future.
“Just because I have HIV doesn’t mean I can’t have babies and that I should be shamed out from the world. No way.”
But there was a time when Janelle didn’t care about life, least of all her own. For nearly a decade, she was a street addict and prostitute. And truth is, she doesn’t know how she became infected. She worked on Queenston Street at age 17, then moved to Vancouver. She was a prostitute. An injection drug user. A street addict driven by her next fix.
She wanted to stop. Desperately, wanted to stop. She had people to support her – people who loved her and who told her she was smart and full of potential – and she had programs and places lined up to help her.
And yet, she couldn’t.
“I said ‘enough’s enough’ a million times.
“I’d get out of jail, and say, ‘I’m not doing that again’. But within a day or two, I’d be doing drugs. Again.
“I couldn’t stop.”
She has lived under the Geneva Street bridge. And she’s had sex without condoms. In Vancouver she slept in cardboard boxes, wore dirty clothes, didn’t shower for weeks, hardly ate and begged for change.
“I didn’t think I was worthy of having a home. I didn’t think I was worthy of having kids, an education, love or a family,” she says.
And then in 2010 something happened. Something she can’t explain, other than to say, “My soul changed.”
She wanted to be a different person. She wanted something more. A nagging, morsel of hope that she was hungry enough to eat: “Maybe I do want to try it,” she thought.
On her own resolve, she joined Narcotics Anonymous. She attended a camp out, a weekend where recovering addicts gather in a big, open space. “My heart was different that day,” she says.
She also sought help from the methadone clinic in St. Catharines to ween herself off street drugs. It was there that she had an HIV test.
The last time she had been tested, was three years earlier, in 2007 when she was in jail. She was negative.
“All the negative tests, they made me feel invincible,” she says.
It was after that narcotics camp weekend, she learned she was positive.
“I was in shock,” she says. “Denial. Fear.”
There was a instant when she felt like running back to the street. Finding comfort in the familiar. Instead, she caught herself with the power of faith. “God didn’t bring me this far in life to drop me on my head now,” she told herself.
“I have nothing. So, I have nothing to lose. Why not give it a shot?”
And so she did.
She had regular appointments with the HIV clinic at McMaster hospital. A few months later, when her blood work went awry, she thought she was sick.
Turns out, she was pregnant.
She had been pregnant once before. Years ago, while living on the street. She was scared and vulnerable, and had an abortion. A decision that, as the drugs ebbed out of her body, became an overwhelming source of the pain, despair, and incredible guilt.
So, Janelle knew this time she would keep the baby.
What she knows now, but didn’t know then, is how important children are in her life.
“I had this longing to be a mother, and to love,” she says.
Drugs and alcohol gave her a temporary satisfaction. Or so she thought. And then she always needed more and more.
Being a mother – loving a child and being loved back – fills that empty place in her soul she used to feed with crack and heroin.
“In this life, I’m satisfied. My spirit is satisfied. I have a lot of love to give, and I get a lot of love from my kids.”
But back when she was pregnant, she was scared. Still, she attended all her appointments through the high risk pregnancy clinic at McMaster. She told them everything about her drug use and sexual history.
“I gave all of me, so I could do the best for my child,” she says.
That included taking the anti-HIV meds during her pregnancy and AZT at the birth. She delivered by C-section and didn’t breastfeed. Noah was given AZT when he was born. And although Janelle was still on methadone, Noah did not experience withdrawal symptoms.
She was able to get off methadone soon after he was born, and has been clean of street drugs ever since. And after a series of blood tests, Noah was confirmed negative for HIV.
By the time Janelle was pregnant with Isaiah, she felt empowered as a mother. She followed all the precautions she had with Noah, including feeding them both formula.
She received free formula for a year through the Teresa Group, an organization that supports children and families affected by HIV and AIDS. It co-ordinates the baby formula program, funded through the Ministry of Health and Long Term Care in Ontario, to reduce the risk of HIV transmission through breast milk.
Isaiah is one blood test away from also being confirmed HIV negative.
In her heart, Janelle believes her life is guided by powers higher than herself.
“I was open to conceive and God said, ‘OK, I agree with your plan’,” she says.
“For me, it was the biggest honour and privilege I’ve ever received.”
Her life now is about appreciating the gift of life. Her own. And her childrens’.
“For somebody who was dying four years ago, to be here. My life is simple. I don’t own a house. I don’t have a ton of money. But I have a plan.”
She hopes to one day become a paediatric nurse.
To the people who judge her life, she is determined to educate them. Yes, she is the sum of her life experiences and that includes being HIV positive. She can’t change that nor can she change the choices she made in her past. She is also a single mother; she has known the boys’ father for many years.
All she can do is go forward, and let her past guide her to make a better future for her children.
She is honest about her HIV and her history. There have been times while bottle feeding her baby on the city bus, that strangers have asked why she is not breastfeeding. At first, she tells them: “I can’t breastfeed. I have a medical condition.”
If they insist on pursuing the question, she is not afraid of a truthful, possibly uncomfortable conversation. “I’ve come to this place where I’m going to give you the truth because HIV MOMit’s not worth it to lie,” she says.
The line that follows is usually: “I’m HIV positive. I can’t breastfeed.”
And while reactions range from the curious who sense her ease of conversation and ask more questions, to the awkward who stumble over such an honest reply, she has never faced negative backlash.
She hopes people will not dredge up old fears.
“I am good enough. I am worthy. I am a good mother. I’m very blessed,” she says.
And one day, her children will know this too.
“They’re going to have a story to tell. And it’s going to be a good story.”
In Canada, it is rare for infants to be born with HIV or to become infected after birth, when the following measures are taken:
Counselling with a doctor about pregnancy planning
HIV testing and counselling before pregnancy
The use of ART(anti-retro viral therapy) during pregnancy so that the mother’s viral load is less than 50 copies/ml
Regular visits to a clinic for care and advice during pregnancy
Use of intravenous AZT and, if medically necessary, sometimes the use of additional medicines for the mother during the birthing process as recommended by Canadian guidelines
Giving birth via Caesarean section (if medically necessary)
Giving the newborn a short course of anti-HIV medicines for further protection
Using formula and not breastfeeding, as HIV can be spread via breast milk
Not pre-chewing food for the baby when solids are introduced. Adults who have both HIV and oral infections can inadvertently cause a small amount of blood to leak and be present in the food that they chew. This blood can contain HIV, and if the pre-chewed food is fed to the infant, it could transmit HIV.
The New York State Court of Appeals on Thursday affirmed a lower court ruling that reduced the charges for a defendant who knowingly infected his partner with H.I.V., in a decision that could limit prosecutors’ ability to charge infected people who don’t disclose their status.
The case, People v. Terrance Williams, stems from a 2010 encounter between two Syracuse men. The men had unprotected sex, and the victim reached for a condom before the defendant took it away from him. The defendant later urged the victim to get tested for H.I.V. before the relationship ended in November 2010.
The victim found out that he had contracted H.I.V. from the defendant in February 2011. He contacted the police after the defendant admitted that he knew he was H.I.V. positive before their relationship began in an apology over social media.
A grand jury charged the defendant with first-degree reckless endangerment, a felony punishable by up to seven years in prison, along with third-degree assault. However, in August 2012, a lower court reduced the felony count to second-degree reckless endangerment, a misdemeanor.
The Court of Appeals heard the case on January 5, with just five sitting judges. (The court returned to its full complement of seven judges last week, when judges Eugene Fahey and Leslie Stein were confirmed by the State Senate after a lengthy delay.)
Government lawyers from Onondaga County argued that, in light of the severe health consequences of H.I.V., the defendant’s actions were depraved.
The court ruling Thursday upheld the reduction of charges, holding that the defendant did not act with depraved indifference (a prerequisite for a reckless endangerment felony). Four of the court’s five judges joined the unsigned ruling.
“There is no evidence that defendant exposed the victim to the risk of HIV infection out of any malevolent desire for the victim to contract the virus, or that he was utterly indifferent to the victim’s fate,” the decision read.
Judge Eugene Pigott dissented, writing that the defendant’s belated remorse was irrelevant to the grand jury’s decision to charge him with a felony.
“The critical inquiry is whether defendant exhibited a depraved state of mind at the time the offense was committed, not whether defendant felt bad about what he had done months after the fact,” Pigott wrote.
The appellate court that last heard the case also ruled that H.I.V. was not an automatic death sentence, in large part due to recent medical breakthroughs. The felony charge of reckless endangerment refers to an action that “creates a grave risk of death,” while the misdemeanor version is only a “substantial risk of serious injury.”
The Center for HIV Law and Policy—along with other public health and medical organizations—had filed an amicus curiae brief on behalf of the defendant, challenging “the DA’s reliance on scientifically unsupported characterizations of HIV that perpetuate persistent ignorance and stigma associated with the virus and those living with it.”
The brief argued that H.I.V. was more difficult to transmit than widely thought, and was a chronic, yet manageable, health condition.
Iván Espinoza-Madrigal, legal director for the Center for HIV Law and Policy, celebrated the “powerful outcome” of the case.
“H.I.V. is not a death sentence,” Espinoza-Madrigal told Capital. “Medical advances must be taken into account, and the court can’t hold on to outdated notions.”
New York does not mandate sexual partners to disclose their disease status, which legal advocates and public health experts say unjustly criminalizes consensual sexual relationships. According to the Center for HIV Law and Policy, 34 states have H.I.V.-specific criminal statutes. New York is one of nine states where prosecutors have used traditional criminal statutes to prosecute H.I.V.-positive defendants.
“When an HIV diagnosis can trigger first-degree reckless endangerment charges, the only behavior likely to be deterred is getting tested and into treatment,” Terrance Moore, director of policy and health equity at the National Alliance of State and Territorial AIDS Directors, said in a statement. “Individuals, and the communities where they live, are at greater risk of disease when the law and rational public health approaches are at odds.”
However, the Court of Appeals didn’t specifically rule on the danger of H.I.V., finding that the lack of depraved indifference on the part of the defendant was enough to affirm the lower court’s ruling.
The defendant will now be tried on misdemeanor charges in trial court.
People make assumptions about the kind of people who get HIV. Some think that it is only an issue for people who are promiscuous, poor, a minority, or gay. With the false safety of these beliefs, people make mistakes that could result in a rude awakening. More than half of young people who are living with HIV are unaware of their status, and HIV infections are on the rise. So don’t be naïve about the kinds of people who can get HIV, because no one is immune to infection and almost everyone has had an experience that could have been life changing.
Here are six common ways that you can become infected with HIV.
You thought he was monogamous
Surprisingly, this is one of the most common ways that people report becoming HIV-positive. When you enter into a monogamous relationship, you shouldn’t have to question your partner’s fidelity or be forced to wear condoms on your wedding night. But that doesn’t mean you should turn a blind eye to the possibility of your partner sleeping with another person. So keep the communication open and the topic of HIV on both of your minds to minimize your risk while maximizing your pleasure.
He didn’t know he was HIV-positive
You like him, he likes you and both of you seem to be as healthy as can be. Of course you would use a condom for a hook-up, but this isn’t a hook-up and condoms are so “unromantic.” Many people feel like sex without a condom is more intimate and a sign of trust. The decision to remove a condom as a relationship progresses can be a very good thing, but not before you’ve been tested together. Remember, more than half of young people living with HIV do not know that they are HIV-positive. And according to the CDC, the majority of HIV infections occur from someone who is unaware of their status. If you skip getting tested together, one of you may unknowingly transmit the disease.
Drugs and Alcohol impaired your judgment
So you claim to wear condoms most of the time, but when examining your most recent sexual romps, the details are a little hazy. Maybe you wore a condom, maybe you didn’t. Drugs and alcohol are one of the biggest risk factors when it comes to the spread of HIV. If you know that your likelihood of wearing a rubber decreases as the drinks start to flow, you may want to take a sobering look at just how risky your behavior may be.
You didn’t ask, he didn’t tell
Naturally, you would assume that anyone who is HIV-positive would disclose his or her status before having sex with you. So you just presume that since they didn’t bring it up, you’re safe. Unfortunately, people fail to disclose all kinds of things, especially when it comes to sex. If you don’t ask, he may not tell you. And in case you need reminding, just because he says he is HIV-negative doesn’t make it true. When it comes to your HIV status, you cannot afford to be too idealistic.
You are a top so you thought you were safe
It’s common knowledge that HIV is a “bottom” thing, right? So when a hot guy is cool with going at it without a condom, you consider it safe. But if the same guy is unknowingly living with HIV and carrying a high viral load, your risk might not be as low as you think. Many men have reported contracting HIV from topping during anal sex. According to a recent study, around one-in-five men who were recently infected were tops.
You thought it couldn’t happen to you
It’s easy to consider HIV as separate from your reality and, therefore, not a threat to your health. Many people living with HIV do so in secret; never revealing their status to their friends and family. This, along with improved medications, has created an environment where people falsely believe that HIV isn’t a part of their world. Don’t be naïve. HIV continues to spread and you are just like everyone else — at risk for HIV.
So get tested, talk about prevention with your friends and your partner, and be aware of the risks you face. Your sexual health depends on it.
Infection with VZV (varicella zoster virus), a member of the herpes virus family, is relatively common. In general, in childhood VZV causes chickenpox and in adults it recurs to cause shingles. After the signs and symptoms of chickenpox resolve, VZV goes into a state of latent infection inside nerve cells. It is generally held in check by the immune system. However, as the immune system weakens with age, VZV can become reactivated, resulting in shingles (also called herpes zoster). Shingles is a painful skin condition that is most commonly seen in people over the age of 50. However, there are cases when the immune system becomes weakened, such as stress from another infection, that can allow the reactivation of VZV leading to shingles even in younger people.
People dealing with the following health issues can also, sometimes, develop shingles:
type 2 diabetes
Focus on HIV
In the time before the availability of potent combination anti-HIV therapy (commonly called ART or HAART), rates of shingles were high among HIV-positive people. Fortunately, ART became available in high-income countries in 1996, and since then serious infections arising from weakened immunity are less common among people taking ART.
HIV, ART and shingles
To better understand trends in shingles cases as well as the impact of ART, researchers in Paris, France, analysed health-related information collected from both HIV-positive and HIV-negative people. They found that cases of shingles decreased significantly once ART became available in France in 1996. However, even after 1996, researchers found that HIV-positive people had a generally elevated risk for shingles. Shingles is relatively common in older people but in the French study HIV-positive people aged 15 to 44 years were at greatest risk for this condition.
Researchers reviewed health-related information collected from major clinics across France and centralized in the French Hospital Database (FHDB). The data from HIV-positive people were collected from 1992 to the end of 2011. Health-related information from HIV-negative people was collected between 2005 and 2008. The data for HIV-negative people was provided by a network of general practitioners (family doctors) called Réseau Sentinelles. This network reports any cases of certain diseases and conditions (including shingles) that occur in France. Other research has shown that this network is broadly reflective of the diseases and conditions that family doctors treat across France.
Researchers analysed data from 91,044 HIV-positive people and found that 7,167 had been diagnosed with shingles. Below is a brief average profile of HIV-positive people with shingles:
72% men, 28% women
age – 38 years
CD4+ count – 304 cells/mm3
lowest-ever CD4+ count – 176 cells/mm3
proportion with an HIV viral load less than 500 copies/ml – 29%
Overall, researchers found that cases of shingles among HIV-positive people fell significantly once ART was introduced.
Among HIV-positive people, there were always more cases of shingles in men than women. However, this difference decreased in more recent years.
Rebuilding the immune system
Untreated HIV infection significantly weakens the immune system. As a result, the immune system may not recognize some germs; even in cases when it does, the immune system may sometimes fail to produce an effective immune response against germs. This dysfunction allows germs to accumulate in the body.
Once a person initiates ART their immune system begins to gradually improve its ability to detect germs and rapidly respond to them. Depending on the degree of pre-ART immunological dysfunction and injury, during the first six months after initiating ART, immunological responses toward germs may not be ideal.
People who have accumulated a high degree of immunological injury prior to initiating ART have an increased risk of inflammatory reactions in the first three months after initiating ART. Such reactions are called immune reconstitution inflammatory syndrome (IRIS). This occurs because the recovering immune system is still somewhat dysfunctional but thanks to ART it can now recognize germs and mount a response to attack them. The response is often exaggerated, perhaps partly driven by a high amount of a particular germ, perhaps driven in part by immunological dysfunction. Whatever the underlying reason, IRIS can cause tissue injury.
Symptoms of IRIS can vary depending on the organ system affected and can range from mild fever and lack of energy to more serious symptoms that can resemble an infection. IRIS reactions are more common in people whose lowest pre-ART CD4+ counts were less than 100 cells/mm3. In all cases, IRIS is driven by an exaggerated inflammatory reaction to a germ. Doctors may prescribe anti-inflammatory agents such as the temporary use of corticosteroids to reduce the intensity of IRIS.
Starting ART and shingles
In the FHDB study, researchers noticed that after 1996 (when ART became available in France) cases of shingles would sometimes occur within three months of participants initiating ART. This is likely the result of participants initiating ART when their immune systems were weakened.
Among HIV-negative people in France, researchers found that half of people with shingles were 60 years or older. Also, shingles in this population was more common in women than in men.
The researchers also found that, overall, HIV-positive people, regardless of gender, were generally three-fold more likely to develop shingles than HIV-negative people. The risk for shingles among HIV-positive people was greatest for people aged 15 to 44 years. In this group, the risk for shingles was six-fold greater than among HIV-negative people.
Once HIV-positive people reached the age of 65 years, their risk for shingles was similar to that of HIV-negative people.
Due to the high risk of shingles among relatively young HIV-positive people, the French researchers stated that “the benefits and safety of VZV vaccination should be studied in [this population].”
They concluded their report by stating: “Clinicians and patients should be aware that ART temporarily increases the risk of shingles during the first six months of treatment.”
About chickenpox and shingles
Below is some brief information about these conditions.
VZV, a member of the herpes virus family, causes chickenpox and shingles.
Chickenpox was formerly a common childhood infection, but is now less common due to routine vaccination of all children in Canada and many high-income countries. In most cases, chickenpox results in a skin rash, low-grade fever and lack of energy. Generally, chickenpox itself is not life threatening. However, because the rash results in skin lesions that can be very itchy, affected children are prone to scratching them, which makes the underlying soft tissue susceptible to infection by bacteria that normally live on the skin. Such so-called secondary bacterial infections can be serious, rarely leading to “flesh-eating disease” (necrotizing fasciitis) and/or toxic shock syndrome. Pneumonia and inflammation of the brain (encephalitis) can also be complications of chickenpox.
According to the Public Health Agency of Canada (PHAC), “complications are more common in adolescents, adults and people with conditions that compromise their immune system who have higher rates of pneumonia, encephalitis and death.” It is also dangerous to infants whose mothers develop chickenpox around the time of delivery.
The virus that causes chickenpox is easily spread through the air when people with chickenpox sneeze or cough. It can also be spread by touching the fluid that comes from chickenpox lesions and by kissing. A person with chickenpox is no longer contagious once all the skin lesions have crusted over.
After signs and symptoms of chickenpox clear, the virus that causes it can go into a state of latency.
Shingles occurs when latent VZV infection becomes reactivated. Although shingles can occur at any age, it is generally most common in adults who are 50 years and older.
Shingles in adults initially appears as an intense tingling or burning pain on one side of the body. This pain is followed by the appearance of red patches and the formation of small sores. Blisters form and these eventually become crusted, dry and fall off. The pain and blisters are usually along the parts of the skin supplied by a single nerve that was latently infected with VZV which has reactivated. While scars from shingles are not common, older adults can sometimes develop persistent burning or tingling pain where their shingles appeared; this is called “post-herpetic neuralgia” and may require treatment. During shingles some people develop symptoms similar to a flu. An episode of shingles usually lasts for between one and two weeks.
Shingles is not spread through the air like chickenpox, but can be spread when a person touches the fluid from a blister. Keeping blisters covered greatly helps to reduce the possible spread of shingles. People with shingles are not infectious before the appearance of blisters or after blisters have become crusted.
In cases of weakened immunity
In people with HIV and other immunological disorders, both chickenpox and shingles can take longer to clear, up to four weeks in some cases. What’s more, shingles can recur in such people.
Treatment of shingles can include the antiviral drugs valacyclovir or famciclovir. These drugs can speed the healing of lesions and sometimes cause a reduction in pain and the risk for post-herpetic neuralgia.
Although vaccines are licensed to reduce the risk of developing chickenpox and shingles, they contain weakened but live virus. People with HIV infection (or parents of children with HIV) should consult an infectious disease or HIV specialist about whether it is safe for them (or their children) to receive these vaccines. If someone with a weak immune system is in contact with a person infected with chickenpox, it is important that they contact their health care provider to find out if they need treatment to prevent developing chickenpox themselves.
Two candidate shingles vaccines are being tested for possible use in people with immunological disorders. These vaccines are:
a heat-treated vaccine – this contains virus that has been treated with heat so that it cannot cause infection. However, it can stimulate immunity to VZV. This vaccine is being developed by Merck.
a subunit vaccine – this contains a protein from VZV that is coupled with a protein derived from bacteria. The purpose of the bacterial protein is to stimulate the immune system when it is exposed to the protein from VZV, amplifying the immune response to VZV. Neither the protein from VZV nor the protein from bacteria can cause infections. This vaccine is being developed by GlaxoSmithKline.
Preliminary results from clinical trials of both of these vaccines suggest that they are safe and cause immunity to VZV.
We thank infectious disease specialist Jason Brophy, MD, for his helpful comments, expert review and research assistance.
—Sean R. Hosein
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